TT.A.  Hor'ci  c na/i~ 


-The,  Occurence,  Of  Hemoly-ric  STre.f^-t-ocoac.  , 
, hau-t~  T’hc^  'l~6€^~th 


>••  ■' 


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THE  OCCURRENCE  OF  HEMOLYTIC  STREPTOCOCCI 
ABOUT  THE  TEETH 


BY 

RALPH  AUGUST  KORDENAT 

B.  S.  University  of  Illinois 
1919 


THESIS 

Submitted  in  Partial  Fulfillment  of  the  requirements  for  the 

Degree  of 

MASTER  OF  SCIENCE 
IN  BACTERIOLOGY  AND  PATHOLOGY 
IN 

THE  GRADUATE  SCHOOL 
OF  THE 

UNIVERSITY  OF  ILLINOIS 


1920 


Digitized  by  the  Internet  Archive 
in  2015 


https://archive.org/details/occurrenceofhemoOOkord 


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THE 


OCCURiCTCE  OF  HEMOLYTIC  STREPTOCOCCI 

ABOUT 

THI] 

TEETH 

Ralph  A.  Kordenat. 


From  the  Department  of  Pathology  and  Bacteriology, 
University  of  Illinois,  College  of  Medicine. 
Chicago,  Illinois. 


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TAELIi:  OF  COITTEIITS 

1.  Introduction 

2.  Literature 

3.  General  Anatomy  of  I’eeth  and  Gums 

4.  Experimental  data 
Collection  of  material 
Method  of  Culturing  Organisms 
Morphology  of  Organisms 
Staining  properties 

Classification  of  Organisms  hy  Fermentation  Tests 
Virulence 

5.  Discussion 

6.  Conclusions 

7;  Table  1.  Incidence  of  hemolytic  streptococci  in 
gingival  space 

8.  Table  2.  Classification  of  Hemolytic  Streptococci 

9.  Table  3.  Varieties  of  Hemolytic  Streptococci 

10.  Table  4.  Virulence  of  gir^gival  Hemolytic  Streptococci 

for  rabbits 

11.  Table  5.  Hemolytic  Streptococci  in  Pyorrhea  Cases 

12.  Figure  1.  Gross  Anatomy  of  Tooth  and  Gums 

13.  Figure  2.  Apparatus  for  collecting  Material  from 

Gingival  Space 

14.  Figure  3.  Method  for  obtaining  Material  from  Gingival 


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The  Occurrence  of  Hemolyolc  StreptoQOcci 
About  the  Teeth. 

Various  investigators  have  shown  that  hemolytic 
streptococci  occur  in  the  normal  as  well  as  in  the 
pathological  oral  cavity  and  upper  respiratory  tract. 
The  object  of  the  investigative  work  recorded  here  is 
to  determine  the  frequency  of  various  hemolytic  strep- 
tococci about  the  teeth  and  gums  in  apparently  normal 
and  in  pathological  cases. 

Literature 

Davis  (18o2)  has  shown  that  hemolytic  streptococcci 
occur  in  the  crypts  practically  constantly  and  upon 
the  surface  in  sixty  per  cent  of  all  tonsils. 

Maclay  (3)  found  in  £68  cases  fourteen  strains  of 
hemolytic  streptococci  in  the  crypts  of  tonsils.  His 
examinations  show  a marked  seasonal  variation,  strep- 
tococci being  fewer  in  the  summer  months,  Voight  (4) 
found  that  thirty  per  cent  of  all  oases  of  severe  in- 
fection of  the  middle  ear,  ethmoids  and  mast o ids  are 
due  to  some  form  of  hemolytic  streptococci  and  that 
these  organisms  occur  in  eighty  per  cent  of  tonsils 
removed.  He  has  isolated  hemolytic  streptococci 


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from  the  urine  of  patients  suffering  with  an  acute 
tonsilitis.  ITichols  and  Eryan  (5)  have  shown  that  a 
high  percentage  of  their  tonsil  infections  is  due  to 
streptococci  and  confirm  Davis'  (6)  ohser  vations  that 
they  may  occur  in  great  numhers  in  the  crypts  of  ton- 
sils, even  when  surface  smears  fail  to  reveal  the  or- 
ganisms. Henrici  and  Hartzell  (7)  helieve  that  mouth 
streptococci  are  the  true  parasitic  organisms  of  the 
mouth  because  they  are  the  only  ones  that  can  live  on 
the  clean  mucous  membrane  before  eruption  of  the  teeth. 
They  observed  that  there  is  a relative  decrease,  but  an 
absolute  increase  of  these  streptococci  in  conditions 
of  uncleanliness  and  decay.  They  also  believe  the 
organisms  in  question  to  be  the  cause  of  dental  caries, 
pulpitis  and  pyorrhea  alveolaris  because;  first,  they 
are  the  only  organisms, in  these  lesions  that  are  patho- 
genic as  exhibited  by  their  local  invasive  pov/er, 
their  ability  to  invade  the  blood  and  lymph  stream  and 
produce  metastatic  infection;  second,  they  are  the 
only  organisms  found  in  the  deep  advancing  borders  of 
infected  tissue;  third,  in  metastatic  abscesses  and 
in  experimental  inoculation  of  animals  the  organisms 
produce  a subacute  aiid  granulomatous  lesion  similar  to 
the  inflammatory  reaction  found  in  pyorrhea  and  chronic 
apical  abscesses;  fourth,  that  the  true  mouth  strepto- 
cocci (Streptococci  salivarius)  - which,  according  to 
Holman's  classification  is  of  the  non-hemolytic  variety  - 


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will  invade  the  dental  pulp  and  peridental  tissue. 

In  a later  work  Henrici  and  Hartzell  (8)  have  fre- 
quently found  hemolytic  and  non-hemolytic  strepto- 
cocci in  dental  pulps  in  cases  of  "both  dental  caries 
and  pyorrhea. 

The  evidence  that  streptococci  are  exciting 
factors  in  the  etiology  of  many  mouth  lesions  and 
that  their  occurrence  in  the  oral  cavity  as  active 
foci  of  infection  responsible  for  many  systemic  con- 
ditions has  been  further  established  by  Hosenow  (9), 
Babcock  flO),  Lescohier  (11),  h'ldridge  (12),  Earl  (13), 
Grieves  (14),  Potter  (15)  and  others.  hosenow,  in 
his  extensive  studies  on  elective  localization,  lays 
much  stress  upon  the  importance  of  anaerobic  cultures 
in  maintaining  the  elective  localization  property  of 
the  bacteria. 

Eurpoean  workers  differ  from  the  majority  of 
American  investigators  as  to  the  exciting  cause  of 
pyorrhea  alveolaris.  Euler  (16)  believes  pyorrhea 
alveolaris  to  be  a spirochetosis,  caused  by  the 
"spirocheta  pyorrheica”  and  influenced  in  some  way 
by  Bacillus  fusiformis,  which  is  normally  present 
in  the  mouth,  but  is  not  pathogenic  UTxless  abui'dant. 
Intensive  arsenical  ( salvarsan)  treatment  with 
proper  oral  hygiene  often  produces  beneficial  re- 
sults. Dufourmentel  and  Frisson  (17)  reported 
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cellulitis  of  the  neck,  phlebitis  of  systemic,  cranial  and 
facial  veins  and  a third  resulting  in  a septicemia  v7ith 
no  anatomic  change.  fhey  recovered  a lor.g  anaerobic 
bacillus,  similar  to  the  hacillus  bellonenses  of  Sacque’ 
pe'e,  that  produced  a fatal  edematous  septicemia  in  guinea 
pigs.  They  apparently  did  not  meet  with  hemolytic  strep- 
tococci in  these  cases. 

Prom  a review  of  the  above  mentioned  literature  it 
is  to  be  noted  that  no  work  has  been  done  on  the  occurrence 
of  hemolytic  streptococci  about  the  teeth  and  gums. 

General  Anatomy  of  feeth  and  Gums. 

A tooth  consists  grossly  of  the  corona  dent  is  or 
crown  with  its  tuberculae  or  cusps,  the  colum  dentis 
or  neck  and  the  radix  dentis  or  root.  (Figure  1)  The 
detailed  histology  need  not  be  considered  here.  The 
roots  of  the  teeth  are  embedded  in  the  alveoli;  to  which 
they  are  accurately  adopted  and  firmly  united  by  a high- 
ly vascular  layer  of  connective  tissue,  the  periostium 
alveoli  (27),  The  periostium  alveoli  is  continuous  with 
the  gums  and  attached  to  both  the  root  of  the  tooth  and 
the  alveolus.  This  attachment  is  so  accurate  and  firm 
that  the  tooth  is  securely  bound  to  the  alveolus  prevent- 
ing any  separate  movement  that  will  cause  undue  stress 
and  strain  upon  the  nerves  and  vessels  entering  the 
apex.  The  gingiva,  however,  is  not  always  in  close 


approxomation  with  the  root  of  the  tooth,  hut  forms  a free 
circular  fold  about  the  crown.  It  was  from  these  spaces 
that  the  material,  to  he  examined  for  the  presence  of 
hemolytic  streptococci  was  collected.  The  procedure 
of  collecting  this  material  will  he  described  later. 

The  blood  supply  of  the  periosteum  alveolare  is 
in  part  from  those  arteries  which  subsequently  enter 
the  apical  foramina  of  the  roots  and  in  part  from  the 
gums.  The  l;^'mph  vessels  from  the  gums  drain  the 
periosteum  alveoli  and  terminate  in  the  submental,  sub- 
maxillary, buccinator  and  superior  deep  cervical  glands. 
Noyes  and  Dewey,  (29)  by  injecting  certain  dyes,  have 
quite  definitely  established  the  existence  of  lymphatics 
in  the  dental  pulp.  It  is  thought  that  those  of  the 
mandibular  teeth  end  in  the  submaxillary  and  deep  cer- 
vical glands.  Those  lymph  vessels  of  the  maxillary 
teeth  pass  partly  by  way  of  the  infra-orbital  canal 
to  the  face,  where  they  join  the  vessels  from  the 
lateral  part  of  the  eyelids  and  terminate  in  the 
anterior  auricular  and  submaxillary  glands. 

Collection  of  Material 

Cultures  were  obtained  from  144  dispensary  and 
hospital  patients  in  the  following  manner.  At  the  time 
of  collecting  the  material  from  these  patients,  the 


presence  or  absence  of  pyorrhea,  gingivitis,  the  general 


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condition  of  the  teeth,  and  wherever  possible,  the  clinical 
diagnosis  were  noted  and  recorded  (Table  1). 

Wooden  applicators  (see  Figure  2)  were  sharpened 
to  a fine  point  and  sterilized  by  means  of  steam*  Five 
millimeter  glass  tubing  was  cut  in  pieces  fourteen  centi- 
meters long  and  one  end  sealed*  These  tubes  were  then 
filled  half  full  of  ordinary  dextrose  broth,  the  wooden 
applicators  inserted  and  the  tubes  then  sealed  with  cot- 
ton plugs*  These  were  then  sterilized  twice  in  the 
autoclave* 

The  sharpened  end  of  the  wooden  applicator  was 
then  inserted  into  the  space  between  the  tooth  and  the 
free  margin  of  the  gums*  From  here  one  can,  in  nearly 
all  cases,  obtain  a large  amount  of  septic  debris  which 
clings  to  the  end  of  the  sharpened  point  of  the  applica- 
tor* The  gums  were  in  no  case  injured  in  obtaining  this 
material  as  the  fine-pointed  end  of  the  wooden  applicator 
was  softened  by  the  broth*  For  this  reason  it  could 
be  inserted  quite  deeply  into  this  dento -gingival  space 
and  is,  therefore,  considered  more  practicable  than  a 
platinum  needle  which,  when  here  used,  invariably  pro- 
duces pain  and  bleeding*  After  the  wooden  point  had 
been  deeply  inserted  between  the  gum  and  tooth  it  was  re- 
placed in  the  glass  container  half  filled  with  nutrient 
broth  and  incubated  at  37°  C.  for  eighteen  hours.  Then 
sub-cultures  were  made  from  the  broth* 


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8. 


Method  of  Culturing 

Serum  hroth  and  "blood  agar  plates  were  inoculated 
from  the  initial  "broth  cultures.  Only  those  colonies 
with  hemolytic  zones  wore  examined  and  from  these  the 
hemolytic  streptococci  were  isolated  and  studied. 

The  growth  of  hemolytic  streptococci  in  no  in- 
stance was  very  a"bundant,  often  there  "being  only  two  or 
three  colonies  upon  the  plates  where  a loopful  of  the 
initial  "broth  (eighteen-hour)  culture  was  made.  Thus 
the  cultures  differ  markedly  from  those  made  from 
material  taken  from  the  crypts  of  tonsils,  which  in 
most  cases  gives  an  almost  pure  culture  of  hemolytic 
streptococci  and  often  in  large  num"bars. 

From  the  144  patients  examined  28  (19,4  per  cent) 
were  positive  for  hemolytic  streptococci  (Ta"ble  1).  In 
one  case  two  distinctly  different  strains  were  o"btained 
in  the  same  patient  - (Ta"ble  2),  One  strain  fermented 
maruiite  and  not  lactose  or  salicin,  while  the  other  fer- 
mented lactose  "but  not  maruiite  or  sa.licin. 

Morphology 

The  twenty-eight  strains  were  isolated  in  pure 
culture  and  studied.  After  the  "blood  agar  plates  had 
"been  incu"bated  at  37°  0.  for  twenty-four  hours,  the 
colonies  of  streptococci  were  removed  with  a wire  loop 


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and  iDlood  agar  slants  and  tales  of  serum  "broth  inoculated. 
Smears  were  made  from  the  twenty-four-hour  serum  "broth 
cultures  and  the  morphology  of  the  organisms  o"bserved. 
They  are  round  cocci  a"bout  one  micron  or  less  in 
diameter,  arrariged  in  chain  formation  and  vary  slight- 
ly in  size.  Often  they  occur  singly.  Frequently 
the  cocci  appear  pressed  together,  especially  in  "blood 
agar  cultures,  Lance-shaped  cocci  have  "been  noted. 

These  are  smaller  than  the  typical  pneumococci  and 
there  is  not  a definite  capsule. 

Staining  Properties 

All  strains  stain  well  with  the  ordinary  dyes 
and  are  Gram  positive. 

Classification 
Fermentation  Tests 


The  twenty-nine  strains  of  hemolytic  streptococci 
( repressnting  twenty-eight  positive  cases)  were  classified 
according  to  the  fermentation  reactions  advocated  "by 
Holman  (18),  After  inoculating  infusion  "broth  with 
Bacilli  coli,  it  was  then  incubated  for  forty-eight 
hours,  sterilized  on  tv/o  alternate  days  in  the  auto- 
clave and  then  filterec’  through  cotton.  To  separate 


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portions  of  this  sugar-free  hroth  lactose,  maru'iite  and 
salicin  were  added.  This  hroth  was  then  tuhed,  litmus 
added  and  sterilized.  Tubes  were  inoculated  with  each 
of  the  twenty-nine  strains  of  the  organisms  and  one  cc 
of  blood  serum  added  to  each.  The  results  are  record- 
ed in  Table  2 and  3. 

There  were  seventeen  strains  of  streptococci 
anginosus.  This  organism  hemolyses  blood  and  ferments 
lactose,  but  it  does  not  ferment  mannite,  salicin  and 
inulin.  Holman  found  this  organism  prevalent  in  nose 
and  throat  infections,  especially  in  scarlatinal  and 
measles  throats.  They  have  also  been  found  in 
endocarditis; 

Five  strains  of  Streptococcus  subacidus  were 
isolated.  These  are  hemolytic  but  do  not  ferment  any 
of  the  carbohydrates  mentioned.  These,  too,  are  of- 
ten found  in  the  throat,  also  in  joint  and  mastoid 
infections. 

Streptococcus  hemolyticus  I was  present  in 
three  cases;  This  streptococcus  gives  biolysis  and 
ferments  lactose  and  mannite,  but  not  salicin.  It  is 
a comparative  rare  strain; 

There  were  two  strains  of  streptococcus  pyogenes 
This  organism  hemolyses  blood  and  ferments  lactose  and 
salicin.  This  strain  of  hemolytic  streptococcus  is  also 
frequently  associated  with  throat  infections.  It  is 
the  common  hemolytic  streptococcus  found  in  pyogenic 
condition's  where  the  streptococcus  is  the  exciting 


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etiological  factor. 

Streptococcus  hemolyticus  II  was  not  found. 

The  Streptococcus  hemolyticus  III  was  found  in  one  in- 
stance; it  is  a hemolytic  streptococcus  that  ferments 
only  mannite.  Holman  found  it  in  empyema  and  in  the 
"blood  of  pueip)eral  sepsis. 

One  strain  of  streptococcus  infrequens  was 
found.  It  is  a hemolytic  streptococcus  that  fer- 
ments lactose,  mannite  and  salicin.  This  is  also  a 
comparatively  rare  organism  and  is  usually  found  in 
throat  conditions,  Kuediger  (19)  isolated  it  from 
otitis  media,  pericardial  fluid,  suppurative  adenitis 
and  conjunctivitis ; Holman  describes  a case  of 
chronic  arthritis  where  this  streptococcus  was  har- 
bored in  the  tonsils  and  after  removal  of  the  tonsils 
the  symptoms  improved; 

The  hemolytic  streptococcus  equi  was  not  found 
among  the  twenty-nine  strains; 

Virulence 

Generally  the  virulence  of  hemolytic  strepto- 
cocci varies  considerably.  Passage  through  animals 
increases  the  virulence,  while  continued  growth  on 
artificial  media  reduces  the  virulence.  The  cell 
substance  possesses  little  toxicity  (19).  The 


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cells  yield  a streptolysin  that  hemolyses  "blood  cells  - 
a true  toxin  containing  a haptophore  and  a toxophore  group 
which,  upon  injection,  will  produce  specific  antibodies 
(EO-21).  This  hemolytic  substance,  however,  is  not 
the  dangerous  endotoxin  of  the  streptococci.  In  1918 
Clark  and  i^'elton  (23)  produced  a filterable,  non-hemolytic 
streptococci  which  would  kill  rabbits  in  doses  of  0.5cc 
per  1000  grams  of  body  weight  of  the  rabbit.  This  work 
has  not  been  confirmed. 

Eleven  rabbits  were  each  injected  intravenously 
with  2cc  of  t\7enty-f  our -hour  serum  broth  cultures  of  the 
hemolytic  streptococci.  These  were  selected  at  random. 

Of  the  eleven  strains  used,  two  proved  to  be  fatal. (Table  4). 
One  of  the  rabbits  (ITo.  2)  died  four  days  after  inoculation. 
The  lung  was  found  hemorrhagic ; otherwise  there  was  no 
anatomical  change.  The  organisms  were  not  recovered 
from  the  body  fluids.  This  was  believed  to  be  due  to 
faulty  incubation.  The  second  rabbit  died  ten  days  after 
injection  of  the  organisms.  There  were  no  s\70llen  joints; 
the  lung  was  hemorrhagic  and  the  organism  was  recovered  from 
the  hearts,  blood  and  bile,  but  not  from  any  joint,  nine 
of  the  rabbits  remained  alive  showir^g  no  ill  effects  v/ith 
one  exception.  Rabbit  ITo.  10,  which  was  injected  with 
a strain  of  streptococcus  pyogenes,  had  distinctly  swol- 
len and  painful  joints. 


It  is  to  be  noted  that  only  two  strains  were 
fatal  to  the  rabbits.  The  pathogenicity  of  hemolytic 


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streptococcus  is  varialDle  for  different  animals.  Battits 
and  mice  as  a rule  are  quite  susceptible.  It  is  knoTTn, 
however,  that  strains  of  streptococci  are  being  passed 
through  one  animal,  thus  Increasing  the  virulence,  will 
not  be  so  highly  virulent  for  another  species  (E3).  Some 
varieties  of  hemolytic  streptococci  (those  often  found  in 
mastitis  in  cows)  may  be  of  low  virulence  for  rabbits, 
though  the  organisms  themselves  are  markedly  hemolytic 
(24).  Animal  tests  may  not,  therefore,  be  a reliable 
index  of  the  virulence  or  pathogenicity  for  man. . 


Discussion 

It  has  frequently  been  shown  that  hemol^iiic  strep- 
tococci occur  in  various  parts  of  the  body,  as  upon  the 
tonsils,  in  the  crypts  of  the  tonsils  (26),  the  hairy 
parts  of  the  bodies  of  filthy  individuals  (25),  the 
ethmoid  and  mastoid  cells  (4),  in  carious  teeth  and 
apical  abscess  (7  and  8),  the  appendix  (26)  and  in 
various  other  localities  without  producing  acute  clin- 
ical manifestations.  In  other  words  these  localities 
may  be  considered  as  frequent  habitats  for  hemolytic 
streptococci. 

Because  of  the  fact  that  the  gingival  space 
(between  the  gingivae  and  the  teeth)  is  anatomically 
suitable  for  the  collection  of  debris  and  because  of 


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14. 


the  above  experimental  data,  it  is  reasonable  to  suppose 
that  the  gingival  space  may  occasionally  act  as  a focus 
of  infection.  In  the  144  cases  examined  fewer  hemolytic 
streptococci  were  found  about  those  teeth  and  gums  to 
which  a tooth  brush  had  been  recently  applied.  The 
majority  of  the  individuals  were  dispensary  and  Cook 
County  Hospital  patients,  most  of  whome  were  grossly 
negligent  concemirig  oral  hygiene.  Henrici  end 
Hart z el  believe,  as  was  previously  mentioned,  that  the 
"Mouth”  streptococci  produce,  in  metastatic  infections 
and  in  e^iperimentally  inoculated  animals,  subacute  and 
granulomatous  lesions  similar  to  the  inflammatory  re- 
actions seen  in  pyorrhea  and  chronic  apical  abscesses. 
This  may  account  for  the  fact  that  the  strains  of  strep- 
tococci injected  into  the  series  of  rabbits  mentioned 
did  not  all  prove  fatal;  It  is  to  be  noted  that  the 
virulence  of  the  twenty-nine  strains  of  hemolytic  strep- 
tococci recorded  here  doss  not  appear  to  be  as  high  as 
that  of  the  hemolytic  streptococci  harbored  in  the  crypts 
of  tonsils,  adenoids  and  upon  the  pharyngeal  mucous  mem- 
brane. The  latter  are  often  highly  virulent  organisms. 
The  possibility  of  some  of  the  organisms  from  the  crypts 
of  the  tonsils  or  from  the  pharyngeal  mucous  membrane 
becoming  disloged  and  subsequently  finding  their  way 
to  the  gingival  spaces  to  reside  there  merely  as  tran- 
sients must,  of  course,  be  considered.  If  this  were 


true  the  decreased  virulence  might  be  explained 


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15. 


In  the  144  patients  examined  nineteen  or  13.1  per 
cent  showed  distinct  clinical  manifestations  of  pj^-orrhea. 
Of  these,  seven  or  36*8  per  cent,  gave  positive  cul- 
tures for  hemolytic  streptococci  (Table  5),  Three 
were  of  the  suhacidus  and  four  were  of  the  anginosus 
varieties.  Many  of  these  individuals  had  other  clin- 
ical manifestations,  and  it  should  be  remembered  that 
the  majority  were  hospital  cases. 

Because  of  the  great  invasive  power  of  the  hemo- 
lytic streptococci  it  is  highly  probable  that  they  can 
penetrate,  not  only  the  fibrous  gingivae,  but  the  al- 
veolar periosteum  as  v/ell.  Here  they  can  be  taken  up 
by  the  numerous  lymph  vessels  and  thence  carried  on  into 
the  blood  stream  producing  metastatic  lesions  elsewhere. 
There  is  certainly  a possibility  tha,t  from  this  favorable 
habitat,  in  the  deep  dento- gingival  spaces,  the  various 
hemolytic  streptococci  may  at  times  act  as  secondary  and 
terminal  invaders. 

Conclusions 

The  method  of  obtaining  material  for  examination 
from  the  gingival  spaces,  as  described,  is  advantageous 
because  it  is  a clean,  painless  procedure  and  does  not 
cause  hemorrhage. 


r<v 

0 . 


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16. 

The  data  presented.  show$  that  19.4  per  cent  of  a 
series  of  144  patients  gave  positive  cultures  of  hemolytic 
streptococci  in  material  taken  from  the  d.anto -gingival 
spaces. 

Of  those  patients  with  well  d.efined.  clinical 
manifestations  of  pyorrhea  31.1  per  cent  gave  positive 
cultures  of  hemolytic  streptococci.  Of  these  three 
strains  were  of  the  Streptococci  suhacid.us  and.  four 
of  the  Streptococci  anginosus  groups. 

Hemolytic  streptococcus  ?/ere  found,  hetwaan  the 
teeth  and.  gums  in  three  out  of  fifteen  cases  of  gingivitis. 

Of  the  various  strains  of  hemolytic  streptococci 
found,  seventeen  were  streptococcus  anginosus,  five  strep- 
tococcus suhacid.us,  three  streptococcus  hemolyticus  I, 
two  streptococcus  pyogenus,  one  was  streptococcus  in- 
frequens  and.  one  was  streptococcus  hemolyticus  III. 

Of  eleven  strains  selected,  at  random,  from 
twenty-nine  strains  of  hemolytic  streptococci  isolated 
from  the  gingival  spaces  of  patients,  two  proved  to  he 
fatal  to  rahhits  in  doses  of  2cc  of  a hroth  culture. 

Both  were  of  the.  anginosus  t3rpe. 

Because  of  the  occurrence  of  hemolytic  strep- 
tococci in  the  deep  dento -gingival  spaces,  these  spaces 
may  he  considered  as  potentially  dangerous  foci  of 
infection. 

There  is  a possibility  that  those  organisms  may 


from  the  above  mentioned  site  act  as  secondary  and 


IC-W. 


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terminal  invaders. 

The  fact  that  hemolytic  streptococci  v/ere  found 
in  only  a small  proportion  of  the  cases  of  pyorrhea 
examined  and  in  these  not  in  great  numbers  indicates  that 
they  are  not  the  primary  etiological  factor  in  this 
condition. 


f r 


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18. 


Eilliography 

1;  Davis  and  Pilot,  -Jour. Inf .Dis . , 1919-24-386. 

2.  Davis,  D;J.,  -Jour.Inf .Dis . , 1912-10-148. 

3.  Maclay,Otis  H.,  -Laryngoscope,  -1919-28-598. 

4.  Voight,  'JiC.R.,  -Jour.Ophth.Otol.Laryngol. , -1917-23-87. 

5.  llioliols&Byron,  -Jour;  A.M.A. , -1918-71-1813. 

6.  Davis, D.J;,  -Jour.  A;M.A;,  -1919-72-319. 

7;  Hartaell&Herarici,  - Jour. Hat .Dent. Asso; , -1917-4-477. 

8.  Henrici&Hartzell,  -Jour. Dent .Research,  -1919-1-419. 

9.  Rosonow,  ii.G.,  -Jour. Hat  .Dent.  Asso. , -1919-3-205. 

10.  Bahcock,R.H; , -IT.Y;Med. Jour . , -1916-104-1086. 

11.  Lescohniar,  A.Y7.,  -Jour.  A;M.A;,  -1917-68-414. 

12.  Sldridge,I7atson  17, , -Dent  .Dig. Chi . , -1919-25-12. 

13.  George,  Bari,  -Lancet,  -1919-n.s.  39-78. 

14.  Grieves, Clarence  J.,  -Dent, Cos.,  -1919-61-819. 

15.  Potter,  Hath.  B.,  -H.Y.Med. Jour . , -1917-105-243. 

16.  Euler,  Therap.  Monatsch.,  Berlin  - 1919-4-133. 

17.  Dufourmental  & Frisson,  Presse.Med.  Paris,  -1918-26-415. 

18.  Holman,  -Jour .Med. Research,  -1916-34-377, 

19.  Ruediger,  -Jour .Inf .Dis . , 1906-3-663. 

20;  Jordan, Edwin  0.  ,-Gen.Bact  .IT.B.SaundersCo.  ,Phil.  ,Pa.-1916-  . 

p . 19  2 . 

21;  Ruediger,  -Jour.  A;M;A. , -1903-41-962. 

22.  BesreJJia,  Ann;  de  1' Inst;Past , , -1901-15-r880. 

23;  Clark  & Felton,  Jour.  A.M.A;,  -1918-71-1048. 

24.  Knorr,  -Ztsch.  fur  Hyg;,  -1893-13-427. 


19. 


25.  Jones,  F.S;,  -Jour ;l2xp. Med.  -1918-28-253. 

26;  Schachter,  Proc;,  Ghi ;Path;Boc ; , -1918-10-301. 
27;  Kraft,  A.,-  Experimental  data  to  "be  pullished. 

28.  Cunningham,  Text,  of  Anat.,  V/m.  Wood  & Go; 

29.  IToyes  & Dewey,  -Dental  Cosmos,  -1917-59-436. 


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TABLE  I 


Incidence  of  hemolytic  streptococci  in  the  gingival  space. 


CASE 

HEM 

PYORR 

GIEGIV 

DEET 

BRIDGES , 

EO 

STREP 

mA 

IT  IS 

CARIES 

GROrmS,ETC 

REMARKS 

1 

0 

0 

0 

0 

Wire  hrace 

B 

0 

0 

0 

+ 

Tor^sillitis 

3 

0 

0 

0 

0 

4 

0 

0 

0 

0 

+ 

5 

0 

0 

0 

0 

6 

+ 

0 

+ 

+ 

+ 

Undergoing  dental 
treatment 

7 

0 

0 

0 

0 

+ 

Chronic  rhino- 
pharyngitis 

8 

0 

0 

0 

+ 

+ 

Chronic  rhinitis 

9 

0 

0 

0 

+ 

+ 

Chronic  rhinitis 

10 

0 

0 

0 

0 

+ 

11 

+ 

0 

0 

0 

0 

2 strains  of 
strep,  recovered 

12 

0 

0 

0 

0 

+ 

"Rheumatism” 

13 

0 

0 

0 

0 

0 

14 

0 

0 

0 

0 

+ 

15 

0 

0 

0 

+ 

0 

16 

0 

0 

0 

+ 

0 

17 

0 

0 

0 

0 

+ 

18 

+ 

0 

0 

+ 

+ 

19 

+ 

0 

0 

+ 

+ 

20 

+ 

+ 

0 

+ 

0 

Chronic  pha.ryn- 
gitis 

i 

[»*■ 

V «■' 

r,.  ■ 

K ' 


»< 

r- 


(S 


hT 


1-2 


CASE 

NO 

HEM 

STREP 

PYORR 

HEA 

GIIIGIV 

ITIS 

DENT 

CiiRIES 

BRIDGES , 
CROATS,  & 

REM/J?ES 

21 

•f 

+ 

0 

+ 

+ 

22 

0 

0 

0 

0 

+ 

23 

0 

0 

+ 

+ 

+ 

24 

0 

0 

+ 

+ 

+ 

Lower  plate 
Neurasthenia 

25 

+ 

0 

+ 

+ 

+ 

Upper  plate-arterio- 
sclerosis 

26 

0 

0 

0 

+ 

+ 

Tuho tympanal  catarrh 

27 

+ 

0 

0 

0 

0 

■ 28 

0 

+ 

0 

+ 

0 

Varicose  ulcer 

29 

0 

0 

+ 

+ 

0 

Chronic  Septic 
arthritis 

30 

0 

0 

0 

0 

+ 

31 

+ 

0 

0 

+ 

+ 

Neuritis 

32 

0 

0 

0 

+ 

+ 

33 

0 

0 

0 

0 

0 

34 

0 

0 

0 

-r 

0 

35 

0 

0 

0 

0 

0 

36 

0 

0 

0 

0 

0 

37 

0 

0 

0 

0 

0 

38 

0 

0 

0 

+ 

0 

39 

0 

0 

0 

0 

0 

40 

0 

0 

0 

+ 

+ 

41 

0 

0 

0 

+ 

+ 

42 

0 

0 

0 

+ 

+ 

43 

0 

0 

0 

+ 

44 

0 

0 

0 

0 

+ 

45 

0 

0 

0 

+ 

+ 

Neuritis 

— . » . - 1 ..1 

'sim  vmic’ .m^  aiko  '\, 
iTxaxr^  <am '■  im  ,t 


1-3 


CASE 

NO 

HEM 

STREP 

PYORR 

HEA 

GIITGIV 

ITIS 

RENT 

CARIES 

BRIDGES , 
CROHIIS.  & 

RELLIRKS 

46 

0 • 

0 

0 

+ 

0 

Pulmonary  T,  B. 

47 

0 

0 

0 

0 

+ 

Chorea 

48 

0 

0 

0 

+ 

+ 

Otitis  media 

49 

+ 

0 

0 

+ 

0 

50 

0 

0 

0 

0 

0 

51 

0 

0 

0 

+ 

0 

52 

+ 

0 

+ 

+ 

+ 

Undergoing  dental 
treatment 

53 

0 

0 

0 

0 

0 

54 

0 

0 

+ 

+ 

0 

55 

0 

0 

0 

+ 

0 

Chronic  laryngitis 

56 

+ 

0 

0 

0 

0 

Recurrent  tonsil- 
litis 

57 

0 

0 

0 

+ 

+ 

Gonorrheal  vagin- 
itis 

58 

0 

0 

0 

+ 

0 

59 

0 

0 

0 

+ 

0 

Chronic  pharyn- 
gitis 

60 

0 

0 

0 

0 

0 

61 

0 

0 

0 

0 

0 

Lues  ? 

62 

0 

0 

0 

0 

0 

Postoperat. 

adhesions 

63 

0 

0 

0 

+ 

+ 

Aortitis 

64 

0 

0 

0 

+ 

+ 

65 

0 

0 

0 

+ 

+ 

66 

0 

0 

0 

+ 

+ 

67 

0 

0 

0 

0 

+ 

68 

0 

0 

0 

0 

+ 

69 

0 

0 

0 

+ 

+ 

T uh 0 - t ymp anal 
catarrh 

70 

0 

0 

0 

+ 

+ 

Pharyngitis 

CASE 

NO 

HEM 

STREP 

PYORR 

HEA 

GINGIV 

ITIS 

PENT 

C/iRIES 

BRIDGES. 

CR0\71TS,& 

REMARKS 

71 

0 

0 

+ 

+ 

4- 

72 

0 

0 

0 

0 

4 

73 

0 

0 

0 

0 

4 

74 

0 

0 

0 

0 

4 

Undergoing  dental 
treatment 

75 

0 

0 

0 

+ 

0 

Undergoing  dental 
treatment 

76 

0 

0 

0 

0 

+ 

77 

0 

0 

0 

0 

0 

78 

0 

0 

0 

0 

0 

79 

0 

0 

0 

0 

80 

0 

0 

0 

0 

+ 

81 

0 

0 

0 

+ 

+ 

TaBio  Pareses 

82 

0 

0 

0 

+ 

+ 

Multiple  sclerosis 

83 

0 

0 

0 

+ 

0 

84 

0 

0 

0 

+ 

0 

85 

0 

0 

0 

0 

0 

86 

0 

0 

0 

0 

0 

87 

0 

0 

0 

+ 

+ 

Struma 

88 

0 

0 

0 

+ 

+ 

Myocarditis 

89 

0 

0 

+ 

+ 

+ 

Struma 

90 

0 

0 

0 

+ 

+ 

Arthritis  deformani 

91 

0 

0 

0 

0 

+ 

Chronic  bronchitis 

92 

0 

0 

0 

+ 

+ 

Neuritis 

93 

0 

0 

0 

+ 

0 

94 

0 

0 

+ 

+ 

4 

Struma 

95 

0 

+ 

0 

+ 

4 

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S/tt-OaT&JbX' 


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flaii;i7C 

J;t4o^’sd  otao^HO' 
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I 


m 


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0 

0 


0 

0 

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0 

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0 

0 

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0- 

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0 . 

0 

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0 

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GIITGIV  mm  BRIDGES, 
IT  IS  C.-UilES  cRO\ras,& 


RELilARKS 


CASE  HEM 
NO  STR.EP 


96 

0 

+ 

0 

+ 

+ 

97 

0 

0 

0 

0 

4- 

98 

0 

0 

0 

0 

0 

99 

* 

0 

0 

0 

0 

100 

0 

0 

0 

+ 

+ 

101 

0 

0 

0 

+ 

0 

102 

0 

0 

0 

0 

+ 

103 

+ 

0 

0 

+ 

0 

104 

0 

0 

0 

+ 

0 

105 

0 

0 

0 

•f 

106 

0 

0 

0 

+ 

+ 

107 

+ 

+ 

0 

0 

108 

0 

0 

0 

+ 

0 

109 

+ 

+ 

0 

+ 

0 

no 

+ 

+ 

0 

+ 

0 

111 

+ 

+ 

0 

H- 

+ 

112 

0 

0 

0 

+ 

0 

113 

0 

0 

0 

+ 

+ 

114 

+ 

0 

0 

0 

115 

+ 

0 

0 

0 

+ 

116 

+ 

0 

0 

0 

0 

117 

+ 

0 

0 

+ 

+ 

118 

0 

0 

0 

0 

0 

119 

0 

+ 

0 

+ 

0 

120 

0 

0 

+ 

0 

Dental  abrasion 


Lower  plate 


A.SL^iio  8s:mo  eifx 


HflO'iX  ii&io 

.'.“•;4H  m.fS  OK  T 


e^itXq  xoVTC^X 


•• 

V 

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0 - 

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3 

’ 

1", 

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a 

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0 

0 

0- 

0 

0 

0 

’ 0-  V 

8C  * 

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0 

■ 'H 

■ 

0 

♦ 

2 

Iji 

♦ 

0 

0 

' t^x 

0 

•»■“  “ 

■t 

. 0 • ^ 

0 

c 

'^XOI 

# 

0 ■ 

0 *•!> 

0 

0 

■’  «0X ' 

0 

0 

0 

♦! 

0 w 

. "i  L-"^ 

0 

0 

1 

0 

► 

0 - .V 

a 

\ 

0 

ddX 

# .' 

0 . 

0>  i 

0 

’^vdb-r 

c 

0 ,. 

. 1 
2? 

4- 

iJtOX 

C ■ 

• 

' • * 

0 

0 

s 0 

mi 

c 

» 

♦•  ' 

0 

m 

«- 

^ BOX 

0 

#- 

0 

s 

Oil 

♦ 

0 

• If 

♦ 

* 

f'  -t  XXX 

0, 

^5, 1/ 

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1 0 

0 

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'if 


T 

,0  '■ 

0 

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til 

'? 

0 

0 

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^IX 

« 

0 

0 

0 

■ 

SIX 

0 

' 0 •:■ 

Q 

0 , - 

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an 

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(#  , 

0 

.-.  ■'*  t.iC  ^ 

- 0 

» 

vxx 

0 

..  * 

0 

0 

0 

0^" 

0 

0 

♦* 

✓ 

0 

all 

f 

c 

♦ 

0 

♦ 

0 

OSS 

s> 

I 


•-•  Ti 


1-6 


CASE 

HO 

HEM 

PYORR 

HRA 

GIHOIY 

ms 

RRHT 

CARIES 

BRIDGES , 
GROWTHS,  & 

H2UAEES 

lEl 

0 

0 

0 

+ 

+ 

122 

+ 

+ 

0 

+ 

0 

123 

0 

+ 

0 

+ 

+ 

Undergoing  dental 
treatment 

124 

0 

0 

0 

0 

0 

125 

0 

+ 

0 

+ 

0 

126 

0 

+ 

0 

+ 

+ 

127 

0 

0 

0 

+ 

+ 

Lower  plate 

128 

0 

0 

+ 

+ 

+ 

129 

0 

0 

0 

-f 

+ 

Mitral  stenosis  8o 
regurgitation 

130 

0 

+ 

0 

0 

Acute  catarrhal 
jaundice 

131 

0 

0 

+ 

+ 

0 

Carcinoma  of 
Esophagus 

132 

0 

0 

0 

+ 

0 

Pulmonary  tuber- 
culosis 

133 

0 

0 

0 

0 

0 

Cardiac  decompen- 
sation 

134 

0 

0 

0 

+ 

0 

Auricular  fibril- 
lation 

135 

0 

0 

+ 

0 

Gastric  ulcer 

136 

+ 

0 

0 

0 

0 

Hyp  emephr  oma 

137 

+ 

0 

0 

0 

0 

Gastric  ulcer 

138 

0 

0 

0 

+ 

0 

Pulmonary  tuber- 
culosis 

139 

+ 

0 

+ 

0 

0 

Gonorrheal  arthri- 
tis 

140 

0 

0 

0 

0 

0 

Hydro-pneumo-thoras 

141 

0 

0 

+ 

+ 

+ 

142 

0 

+ 

0 

+ 

0 

Chronic  nephritis 

aTM,  V'IO W 


saiLO 

ASM  . OH 


”„t?^  r< 


.'  €ji>CT34*al* 

-■ 


tt  u UJC<?  J 


I eSeo^b^M  Lsn^ttK 

*0  /icAoafj'cftO' 
staoIXTO 

-rro  ^ocei^ 

ttoi:>j8T2 
• £ittJ|5-  -si^rXrsii'jLai 
S02  .tci 
iso/y  oi^jfaa-? 

AJirci  xri;q»  ma  ^S 

•reoXj?  Ql*^t:e»s 

dl80i</0 
-Yri4'*ia  IstBifvxomif 
«i!# 

: - 0<J**D  Oflij-  - o\i 

J 


♦ 

>♦■ 

p 

^ 0, 

0 

XSI 

0 

0 

'i 

* 

isi* 

W , 

♦ 

0 

•v'*?  n.”’ 

0 

iVj 

0 

0 

0 

,0  j 

0 1 

w 

0 

■i'-" 

e 

m ^ 

i,»i.  > 

H&t 

i4n 

0 

■ :i 

Q 

d&i 

1 % 

,vv 

'•4l 

y»  * 

• 

V- 

0 

0 

0 

7!tC 

1 

4 

iM 

0 , 

jm  . 

♦ 

# * 

♦ 

0 " 

‘eax 

br' 


r -..iT  '*n» 


u 

0 

0 

0 

i»'; 

0 

0 

o 

0 


0 

Q 


0 

•*' 

c 


•IP. 


0‘ 

J 

0 


:>i 


•«SX 
a-  0 


le#" 


+ 

.rP 

• 6.. 

i 0 

1 

' G 

0 ' 

0 

& 

" 0 

■■-*■, 

• 

0 

0 

4^  0 

’f*' 

t 

* 

j -sr  • 

0 

, • t 

'■I^'  0 1 

dSX' 
^ a 

^iL’i 

0 

ij 

0 

dSI 

g J 

0 

0 

0 

7BI 

: 41 

-1 

i 

♦ 

O' 

0 

0 

■ 

0 


I ♦ 


♦ . 

o ' |j 

0 


o 

0 

0 


d 


CASE  mu  PYORR  GIIIGIV  lEiTT  BRIlXtES, 
EO  STREP  HEA  IT  IS  CARIES  GROWTHS,  & 


143 


0 


0 


0 


144  0 


0 


0 


TOTAL 


28 

19 

15 

91 

74 

or 

or 

or 

or 

or 

19.4 

13;1 

10  ;4 

63.1 

51 

per 

per 

per 

per 

per 

cent 

cent 

cent 

cent 

cent 

RELIARKS 


Carcinoma  of  stomac 

Lethargic  ence- 
phalitis 


Total 


TABLE  II 


Glassification  of  Hemolytic  Streptococci 

(Holman) 


CASE 

NO 

LACTOSE 

immiTE 

SilLICIN 

Vj\RISTY 

2 

+ 

0 

0 

Str.  anginosns 

6 

0 

0 

0 

Str.  suLacidus 

7 

+ 

0 

0 

Str.  anginosus 

11 

0 

+ 

0 

Str.  hemolyticiis  11 

IIB 

+ 

0 

0 

Str,  anginosus 

18 

+ 

0 

0 

IT 

19 

+ 

0 

0 

n 

20 

0 

0 

0 

Str,  subacidus 

21 

+ 

0 

0 

Str.  anginosus 

25 

+ 

0 

0 

Str.  ” 

27 

+ 

0 

0 

Str. 

31 

+ 

0 

0 

Tl 

49 

+ 

0 

+ 

Str.  pyogenes 

52 

+ 

0 

0 

Str.  anginosus 

56 

+ 

0 

+ 

Str.  pyogenes 

99 

0 

0 

0 

Str.  subacidus 

103 

+ 

+ 

0 

Str.  hemolyticus  I 

107 

0 

0 

0 

Str.  subacidus 

109 

+ 

0 

0 

Str.  anginosus 

. ■*‘•1  -. 


" ■'.•I,;  ,,| 


■f\  ■-• 


«Y5#^X^  Vt 
v^.  -Si,' 

tU : 


V I ii ' * 1 


■j?'  sppl»^^  - 0 

^ . _■  y. 


k ' 


UUt'^ViC.T 


f , 


9 


TT-2 

C/iSE 


NO 

LACTOSE 

MKITE 

S.\LICIII 

VARIETY 

110 

+ 

0 

0 

Str.  anginosus 

111 

+ 

0 

0 

TT 

114 

+ 

0 

0 

TT 

115 

+ 

+ 

0 

Str.  hemolyticus  I 

116 

+ 

0 

0 

Str.  anginosus 

117 

+ 

0 

0 

Tt 

122 

0 

0 

0 

Str.  suLacidus 

136 

+ 

0 

0 

Str.  anginosus 

137 

+ 

+ 

0 

Str.  hemolyticus  I 

139 

+ 

+ 

+ 

Str.  infrequens 

4 


V.  1 

t 


'*•  f >ii.' 


■WS 


■■■  ft . ,\ 


I 


%i 


r-. '.i  , ' 


, =J  'V.  .■  . *•■' 
'■><  ' . _ 


• * 


■ ^ ■*  '* 

♦•  "* 

r-F ' - 

I?  ^ <1^  < k ''!>** 


^ ,-r 


‘Wi 


t 

/j  ■ 
ir\^  - ■ 

•.©•' 


y.  *■ 

Vb- 


rf 


•TV 

h 


0 


^-4'>  .t . 

0 


TABLE  III 


® ies  of  Hemolytic  Streptococci 


Variety  of  Humber  of 

Hemolytic  Streptococci  Strains  Per  Cent 


Streptococci  Anginosus 

17 

5B.6 

Streptococci  Subacidus 

5 

17.  E 

Streptococci  Hemolyticus  I 

3 

10.3 

Streptococci  Pyogenes 

E 

6.8 

Streptococci  Hemolyticus  III 

1 

3.4 

Streptococci  Infrequens 

1 

3.4 

Streptococci  Hemolyticus  II 

0 

0 

Streptococci  Equi 

0 

0 

^-ndtmSz 


*■  ■ ■% 


-ST——**'* — *Hsrr-  ■ 

jr  p 


"'I 


' *.  r ■ 

*1V  . ^ 


C 


►’.a 


A,.-; 

H"s»  • * 


:t.ajp 

At 

f . ?■  ?«Liyi:'%'r 

-f*|L(*lfV 

SilW'l 

••  . •-  :■  .^rfSK  --..^M 

>'.  '.'2-.a 


r. 

j 

c 


M' 


ja 


>JiKVt»:£^ 


ra 


« wEi 

«-—  ‘ ■ ^1 

E Vp. 

■' .,  W* 

' ■I  .a: 

M ■ ■'  '■ 

U 


[pits 

ijiti 


iu 


% 


m- 


TABIE  IV 


Virulence  of  gingival  hemolytic  streptococci  for  Rabbits 


Rabbit 

No 

Strain 

Variety  of  Clinical 

Streptococci  Manifestations 

Animal 

Inoculation 

1 

52 

Str.  anginosus 

- 

Multiple 

arthritis 

2 

19 

TT 

head  14  days 
(cause  unde- 
( termined) 

3 

27 

tl 

Multiple 

arthritis 

4 

114 

TT 

gonorrheal 

arthritis 

head  10  days 
(Strep. Sep- 
( ticemia) 

5 

49 

Str.  pyogenes 

- 

ho  symptoms 

6 

20 

Str.  subacidus 

pyorrhea- 

pharyngitis 

n n 

7 

139 

Str.  infrequens 

- 

TT  TT 

8 

18 

Str.  anginosus 

- 

TT  TT 

9 

21 

tt 

pyorrhea 

TT  n 

10 

56 

Str.  pyogenes 

tonsillitis 

Arthritis 

11 

107 

Str.  subacidus 

pyorrhea 

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TABLE  V 


Hemolytic 

streptococci  in  Pyorrhea  Cases . 

CASE 

HEM 

VARIETY  OP 

OTHER  CL  III  I CAL 

no 

STEEP 

HEM.  STREP. 

MNIPESTATIONS 

20 

+ 

Str.  subacidus 

Chronic  pharyngitis 

21 

+ 

Str.  anginosus 

- 

2B 

0 

- 

Varicose  ulcer 

95 

0 

- 

96 

0 

- 

- 

107 

+ 

Str.  subacidus 

- 

109 

+ 

Str.  anginosus 

- 

110 

TT 

- 

111 

+ 

TT 

- 

119 

0 

- 

- 

120 

0 

- 

- 

122 

+ 

Str.  subacidus 

- 

123 

0 

- 

- 

125 

0 

- 

- 

126 

0 

- 

- 

130 

0 

- 

Catarrhal  jaundice 

142 

0 

- 

Chronic  nephritis 

143 

0 

- 

Carcinoma  of  stomach 

144 

0 

- 

Lethargic  encephalitis 

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